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Evercare at Stearns

3900 Stearns Avenue, Granite City, IL 62040 · For profit - Limited Liability company · 109 certified beds · (618) 931-3900 Medicare & Medicaid certified

Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Flagged for abuse1 immediate-jeopardy citation$279,894 in federal fines1 Medicare payment denial
Insights

This home has serious findings on its record. Read them closely before you consider it.

Worth asking about
  • CMS has flagged it for abuse
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Jan 2026
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 1 immediate-jeopardy problem — the most serious level
  • a high number of inspection citations overall (38) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $279,894 in federal fines (most recent 2025-12-16)
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • its facility-reported quality-measure rating is low (1/5)
  • nursing-staff turnover (76%) runs well above the national median (45%)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Hospital
★★ 2/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3908 Maryville Rd · (618) 931-1335 · Call to confirm hours
Pharmacy
1537 Johnson Rd · (618) 451-4200 · Call to confirm hours
Grocery
2230 Pontoon Rd · (618) 877-1114 · Call to confirm hours
Park
2199 Amos Ave · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 2 to 1 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating1★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased32.5%13.4%15.4%worse
Long-stay residents who lose too much weight11.5%6.3%5.4%worse
Long-stay residents with a catheter left in their bladder0.4%0.9%0.9%better
Long-stay residents with a urinary tract infection1.6%1.5%2.0%better
Long-stay residents with depressive symptoms27.7%54.2%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.1%0.1%better
Long-stay residents with falls causing major injury2.1%3.1%3.3%better
Long-stay residents whose ability to walk worsened27.1%14.3%16.1%worse
Long-stay residents on antianxiety or hypnotic medication32.2%18.3%18.9%worse
Long-stay residents given the seasonal flu vaccine96.2%91.8%95.3%typical
Long-stay residents with pressure ulcers4.0%4.8%4.7%better
Long-stay residents with worsening bladder/bowel control25.4%20.6%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table37.5%21.7%17.1%worse
Short-stay residents who newly got an antipsychotic medication2.8%2.2%1.4%worse
Short-stay residents given the seasonal flu vaccine26.3%63.1%79.4%worse
Short-stay residents rehospitalized after admission25.1%26.1%22.6%worse
Short-stay residents with an outpatient ER visit22.0%13.9%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.552.021.67typical
Long-stay outpatient ER visits per 1,000 resident days2.462.221.80worse

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

33.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

33.8%U.S. median 51.5%
Got home and stayed home
9.9%U.S. median 10.7%
Went back to hospital
51.4%U.S. median 56.6%
Met the expected recovery
0.12U.S. median 0.31
Therapy hours / resident / day
0.06hours / resident / day
Physical therapy
0.06hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 51.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 35 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.12 therapist hours per resident per day in 2026Q1 — more than 8% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF33.8%CMS range 17.5–47.851.5%Oct 2022–Sep 2024worse than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.9%CMS range 6.8–15.810.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge51.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge57.1%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge45.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified73.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened4.1%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.9%CMS range 3.7–11.47.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.221.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.27
RN hours/ resident / day
0.71
LPN hours/ resident / day
2.10
Aide hours/ resident / day
3.07
Total nurse hours/ resident / day
0.28
RN hoursweekends
75.9%
Total nursing turnover
77.8%
RN turnover

How full it usually is: this home is certified for 109 beds and averages 103.6 residents a day — about 95% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.07 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.27 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.10 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.67 hrs/resident/day on weekends vs 3.23 on weekdays — 17% thinner on weekends. RN hours go from 0.26 to 0.28 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 76% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

12
deficiencies at the latest standard inspection (2025-04-28)
3
at the previous standard inspection (2024-06-18)

Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

38 citations, most serious first. The 24 most serious are shown; the remaining 14 are one tap away and print in full.

  • Immediate jeopardy · Jcited before2024-12-26 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to assess, monitor, and provide timely treatment for 1 of 3 (R3) residents reviewed for change in condition. This failure resulted in R3 experiencing a decline in Activities of Daily Living (ADLs) from 11/30 through 12/4 and subsequently becoming unresponsive on 12/4/24 at 9:00 AM with no medical treatment until 4:00 PM. At the time of ambulance transfer, R3 had Cardiac Pulmonary Resuscitation performed, and intubation. R3 was hospitalized with diagnosis of cardiac arrest, cause unspecified and Severe Septic Shock. This failure resulted in an Immediate Jeopardy, which was identified to have begun on 11/30/24 when the facility failed to: 1. assess, monitor, and provide timely treatment for a change in R3's condition. 2. Notify the physician of R3's decline in ADLs from 11/30 through 12/4 and being unresponsive on 12/4/24 at 9:00 AM. 3. Obtain medical treatment for R3's change of condition from 9:00 AM to 4:00 PM at the time of ambulance transfer with R3…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gdisputed · IDR2026-06-30 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to ensure dependent residents received assistance with nail care and shaving for 1 of 3 (R3) residents reviewed activities of daily living in a sample of 59. This failure resulted in R3 being embarrassed about her appearance. A reasonable person, who was not a dirty person, would likely feel embarrassed about their appearance when their nails are dirty and has long facial hair.Findings include:On 6/22/2026 at 1:50 PM R3 observed sitting in wheelchair with head down. R3 had long facial hair and dirty nails. On 6/23/2026 at 9:00 AM R3 observed sitting in chair with long facial hair to chin. R3's nails were long and dirty.On 6/23/2026 at 10:09 AM R3 sitting in room facing window. Long facial hair remains to chin.On 6/23/2026 at 3:04 PM V58, R3's family, stated that R3 was not a dirty person. V58 stated that R3 did not have facial hair, and her nails were never dirty. V58 stated that R3 would be embarrassed if she saw herself.On 6/30/2026 at 10:30 AM V2, Director of Nursing, stated that she was aware of R3's facial hair and dirty…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2026-01-16 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure residents were free from resident-to-resident abuse for 3 of 3 residents (R2, R7, and R9) in a sample of 24. This failure resulted in R3 physically assaulting R7 and R7 being sent out to the hospital and receiving staples for a head laceration, R9 being slapped on the right side of his face and a red area appearing, and R2 being struck in the face with a cane and sustaining a laceration to her right jawline. Findings Include: R3's Local Hospital Referral, admission date of 09/30/25, documented the following: History of Present Illness (HPI)/Subjective.Patient (Pt) is a [AGE] year-old African American male with past medical history of dementia and Traumatic brain injury. Patient currently lives with wife at home. Per wife patient gets more confused as the day goes on. He does become physically aggressive at night often leaving bruises on her. Patient also tries to escape the residence. Patient is alert to self only. It also documented on 9/29/25:…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-12-16 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility failed to ensure sexual abuse did not occur for 1 of 4 residents (R3) reviewed for abuse and neglect of a sexual nature in the sample of 6. This failure resulted in R2 touching R3 inappropriately when R3 could not deny the advances or give her approval or consent. R3 was incapable of declining to participate in the sexual act and lacks the ability to understand the nature of the sexual act. Findings include: 1-R2's Physician Order Sheet for December 2025 documents a diagnosis of dementia, COPD (Chronic Obstructive Pulmonary Disease), major depression disorder, and muscle weakness, abnormalities of gait and mobility. R2's Minimum Data Set (MDS) dated [DATE] document R2 was moderately impaired for cognition for activities of daily living. Resident does not use a wheelchair or scooter. Sit to stand supervision or touching assistance and walk 10 feet and 50 feet with two turns. R2's Care Plan with a focus date of 11/22/2025 (R2) has had sexual behavior noted related…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2025-04-28 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview, Observation, and Record Review, the Facility failed to maintain a resident's privacy and dignity for 4 of 6 residents (R18, R38, R56, R63) reviewed for resident privacy and dignity in the sample of 79. This failure resulted in R18 and R63 feeling embarrassed and uncomfortable. A reasonable person would expect to have privacy in their home and would experience anxiety, humiliation, and embarrassment if their privates were exposed. The Findings Include: 1. R18's admission Record, dated 4/22/25, documents R18 was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction, Dysphagia, Dementia, Major Depressive Disorder, Anxiety Disorder, Trigeminal Neuralgia, and Morbid Obesity. R18's Care Plan, dated 11/6/24, documents R18 has an ADL (Activities of Daily Living) self-care performance deficit related to Limited Mobility. Interventions: Toilet Use: R18 is not toileted, she is frequently incontinent, unable to transfer to toilet, use of bedpan encouraged, incontinent care per staff.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-04-28 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent abuse for 4 of 4 (R36, R38, R88, R90) residents reviewed for abuse in the sample of 79. This failure resulted in R36 suffering psychosocial harm and feeling scared, unsafe, unable to protect himself and less of a man. This failure also resulted in R90 suffering harm and being hit in the face, stomach and leg by another resident and R88 having a scratch to upper lip. 1. R36's Care Plan, not dated, does not document R36's risk for or interventions to prevent abuse. R36's Minimum Data Set (MDS), dated [DATE], moderately cognitively impaired. On 4/21/2025 at 9:27 AM observed R36 and R38 striking each other with closed fist. R38 yelled out and struck R36 repeatedly, with closed fist on the arm, hand and shoulder. R36 then grabbed R38's arm and swung closed fist at R38, making contact with R38's chest. R38 continued to yell out and push the door into R36's wheelchair and R36's arm. V29, Safety Aide, intervened and attempted to calm the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-04-28 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview, Observation, and Record Review, the facility failed to identify and treat a resident's wounds for 1 of 4 residents (R18) reviewed for wound care in the sample of 79. This resulted in R18 experiencing severe excoriation, including skin breakdown and pain. The Findings Include: R18's admission Record, dated 4/22/25, documents R18 was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction, Dysphagia, Dementia, Major Depressive Disorder, Anxiety Disorder, Trigeminal Neuralgia, and Morbid Obesity. R18's Care Plan, dated 11/6/24, documents R18 has an ADL (Activities of Daily Living) self-care performance deficit related to Limited Mobility. Interventions: Toilet Use: R18 is not toileted, she is frequently incontinent, unable to transfer to toilet, use of bedpan encouraged, incontinent care per staff. It continues (4/7/25) R18 has potential for impairment to skin integrity related to impaired mobility, current medications, incontinence of B&B (bowel and bladder). Interventions:…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2025-04-28 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review the facility failed to ensure safety as indicated per plan of care for 4 of 4 (R11, R17, R53, R72) residents reviewed for accidents and hazards in the sample of 79. This failure resulted in R72 suffering multiple falls and receiving a skin tear to her right knee. Findings include: 1. R72's face sheet documented she was admitted to the facility on [DATE] with diagnosis of, in part, neoplasm of brain, dementia, and neoplasm of lung. R72's MDS dated [DATE] documented she is moderately cognitively impaired and required supervision or touching assistance for all transfers, walking, and going from a sitting to a standing position. R72's Care Plan dated 1/7/25 documented she has high risk for falls related to confusion, gait/balance problems, psychoactive drug use, mood adjustment disorder and anxiety. Fall risk interventions put in place included: for 2/25 0900: provide sign on walker to remind resident to use walker when ambulating added on 3/4/25, for 2/25 1200:…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-12-26 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to notify the physician of R3's change in condition and unresponsive episode for 1 of 3 (R3) residents reviewed for change in condition. This failure resulted in R3 experiencing a decline in Activities of Daily Living (ADLs) from 11/30 through 12/4 and subsequently becoming unresponsive on 12/4/24 at 9:00 AM with no medical treatment until 4:00 PM. At the time of ambulance transfer, R3 had Cardiac Pulmonary Resuscitation performed, intubation. R3 was hospitalized with diagnosis of cardiac arrest, cause unspecified and Severe Septic Shock. Findings include: R3's Care Plan, dated 11/5/2024, documents Advance Directives: R3 is a full code and requests life sustaining measures. R3's Minimum Data Set, dated [DATE], documents that R3 is cognitively intact, occasionally incontinent of urine and always continent of bowel and requires assistance with activities of daily living (ADL). R3's POLST (Physician Orders for Life-Sustaining Treatment), dated 8/5/2024,…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2024-12-26 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility neglected to provide necessary medical services including assessing a change in resident's condition and recognizing when a resident needs emergent medical intervention. This failure resulted in the medical neglect of R3, who did not receive needed emergency medical treatment in a timely manner despite, over the course of five and a half hours, R3 exhibiting a significant decline in condition and subsequently becoming unresponsive on 12/4/24 at 9:00 AM with no medical treatment until 4:00 PM. At the time of ambulance transfer, R3 had Cardiac Pulmonary Resuscitation performed, intubation. R3 was hospitalized with diagnosis of cardiac arrest, cause unspecified and Severe Septic Shock. Findings include: R3's Care Plan, dated 11/5/2024, documents Advance Directives: R3 is a full code and requests life sustaining measures. R3's Minimum Data Set, dated [DATE], documents that R3 is cognitively intact, occasionally incontinent of urine and always continent of bowel and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-10-19 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review, the facility failed to prevent resident to resident sexual abuse for 2 of 8 residents (R3 and R4) reviewed for abuse in a sample of 22. This failure resulted in harm as a reasonable person would not engage in sexual encounters without the decisional capacity to do so. Findings include: R3's Face Sheet, print date of 10/02/23, documents R3 has diagnoses of cognitive communication deficit, altered mental status, and dementia. R3's Minimum Data Status (MDS), dated [DATE], documents R3 is moderately cognitively impaired, with a Brief Interview for Mental Status (BIMS) score of 11 out of 15. R3's MDS documents R3 requires extensive assistance of two plus person physical assist with bed mobility, transfer, and toilet use. R4's Face sheet, with a print date of 10/02/23, documents R4 has diagnoses of personal history (Hx.) of traumatic brain injury, and Major depressive disorder. R4's MDS dated [DATE], documents R4 is moderately cognitively impaired with a BIMS of 08 out of 15. On…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-05-09 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to prevent misappropriation of resident property for 1 of 1 resident (R26) reviewed for misappropriation of property in a sample of 51. This failure resulted in R26 being upset and being a victim of theft of over $2000.00. Findings Include: On 5/3/2023 at 11:00 AM R26 was sitting up in her room in her chair. R26 stated she lived at the facility in the past and was discharged home then was recently readmitted to the facility. R26 stated she noted there were fraudulent charges on her bank card, but she didn't know what was going on because she had the bank card in her possession. R26 stated her family notified the local police regarding the fraudulent charges on her bank card. R26 stated the police told her and her family that a housekeeper that was employed at the facility took a picture of her bank card at the facility without her knowledge and made all purchases online. R26 stated she didn't know how someone had her bank card and she was told a…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-05-09 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to obtain timely emergency medical services for the treatment of a fracture for one of one resident (R62) reviewed for quality of care in a sample of 51. This failure resulted in delay of treatment after R62 fell sustaining an acute and nondisplaced distal radial fracture as well as an acute fracture of the ulna styloid. Findings include: R62's Undated Face Sheet, documents she was admitted on [DATE]. R62's Quarterly Minimum Data Set (MDS) dated [DATE] documents R62 is severely cognitively impaired, supervision with walk in room and corridor, supervision with dressing, limited assistance with one-person physical assist for personal hygiene. R62's MDS documents steady always during balance during transitions and walking and uses mobility devices. R62's Nurse's Note, dated 10/31/2022 no documentation of fall. R62's Bath Skin assessment dated [DATE], V12, Licensed Practical Nurse (LPN) documents, No swelling, bruising or redness to right hand, fingers or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · Gcited before2023-05-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY A. Based on interview and record review the Facility failed to provide supervision to prevent elopement for 1 of 1 resident (R65) from eloping in the sample of 51. This failure resulted in R65 being transferred to local hospital and treated for abrasions. B. Based on interview, and record review, the facility failed to implement safe transfer techniques and implement progressive interventions to prevent falls and accidents for 4 of 4 residents (R59, R47, R62) reviewed for supervision to prevent accidents in the sample of 51. Findings include: A. R65's Face Sheet documents R65 was admitted to the facility 7/3/2021 with diagnoses of Dementia, Schizophrenia, Hyperlipidemia, and Major Depressive Disorder. R65's Risk of Elopement Evaluation, dated 12/19/2022, documented R65 is alert and oriented has a history of leaving, increased risk, ambulates independently. R65's Care Plan dated 7/3/2021 documents (R65) has a history of wandering and attempts to leave related to behavioral issues. The Care Plan documents she…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-06-30 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — pattern
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, observation, and record review, the facility failed to Implement fall interventions to reduce falls for 2 of 5 residents (R3, R7) reviewed for resident safety in the sample of 59. The findings include:1. R7's admission Record, dated 6/25/26, documents R7 was admitted to the facility on [DATE] with diagnosis of Dementia, Alzheimer's Disease, Generalized anxiety disorder, Bipolar disorder, Major depressive disorder, Seizures, Metabolic encephalopathy, Type 2 Diabetes Mellitus (DM), Chronic Obstructive Pulmonary Disease (COPD), Hypertension (HTN) Asthma, Osteoarthritis, and Obesity. R7's Care Plan, dated 5/28/26, documents R7 is at risk for falls and has experienced falls related Poor Balance, Unsteady gait and failure to use her assistive device. Interventions: 1/5/26: Encourage resident to propel in wheelchair (w/c) independently. If resident requests assistance, encourage use of bilateral foot rests during staff assisted propulsion in wheelchair. 10-15-25: Staff to assist resident with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-06-30 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations and record review, the facility failed to provide complete incontinent care for 4 out of 5 residents (R8, R3, R19, R36); reviewed for incontinent care in a sample of 59.Findings include: 1.R8's Facesheet with a print date of 6/25/26 documented she was admitted on [DATE] with diagnosis of, in part, chronic obstructive respiratory disease, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and major depressive disorder. R8's Minimum Data Set (MDS) dated [DATE] documented R8 was cognitively intact, has upper extremity impairment on one side, lower extremity impairment on both sides, is dependent on staff for toileting hygiene, and always incontinent of urinary and bowel. R8's Care Plan dated 5/21/25 documented she has bowel incontinence with interventions of, in part, for staff to provide pericare after each incontinent episode. On 6/24/26 at 9:46 AM, V42 (licensed practical nurse/LPN) and V14 (certified nursing assistant/CNA) came to assist R8…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-06-30 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review the facility failed to maintain a comfortable and good repair environment for 1 of 3 (R3) residents reviewed for bed mobility in a sample of 59.Findings include:1. On 6/22/2026 at 2:19 pm observed R3's mattress sunken in the middle. Observed a hole in the mattress. Observed V6, Licensed Practical Nurse, and V22, Certified Nurse Assistant, transfer R2 into bed.On 6/23/2026 at 3:40 PM V18, R3's family, stated that R3 has a hole in her mattress and she has notified the facility repeatedly. V18 stated that this is ridiculous. V18 would not live like that. When the mattress is worn or has a hole you replace it. On 6/29/2026 at 9:35 AM a mattress observed sunken in the middle with a hole in mattress.On 6/29/2026 at V16, Certified Nurse Assistant, stated that she doesn't usually work the hall. V16 verified that R3's mattress was sunken in the middle with a hole in the mattress. V16 stated that she is not sure how long the hole has been there. V16 stated that laying the sunken mattress and the hole would be uncomfortable.The facility's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-12-16 · tag F0607 — failed to have anti-abuse policies — isolated
    Develop and implement policies and procedures to prevent abuse, neglect, and theft.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to operationalize their abuse policy and procedures for 2 of 4 reviewed (R2 and R3) for policies in the sample of 6. On 12/5/2025 at 8:35 AM, V1, Administrator stated we did have an incident with (R2) and (R3), but (R3) could not tell you anything. When we interviewed (R2) she was confused, and she said she just thought she was helping (R3) because she used to be a CNA (Certified Nursing Assistant) and her roommate's (adult diapers) were full of BM (bowel movement) and it was just a big misunderstanding. On 12/5/2025 at 8:45 AM, V1 stated the Facility was requesting past noncompliant (PNC) for F600 abuse even though through their investigation they had no findings. V1 stated they did not believe the abuse occurred because (R2) use to be a certified nursing assistant, at this building. They did a PNC ready just in case. On 12/5/2025 at 8:49 AM, V2, Director of Nursing stated they did an internal investigation and felt like (V4) jumped the gun…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-12-16 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the Facility failed to ensure all alleged violations are thoroughly investigated for 2 of 4 residents (R2 and R3) reviewed for abuse investigations in the sample of 6. Findings include: On 12/5/2025 at 8:35 AM, V1, Administrator stated we did have an incident with (R2) and (R3), but (R3) could not tell you anything. When we interviewed (R2) she was confused, and she said she just thought she was helping (R3) because she used to be a CNA (Certified Nursing Assistant) and her roommate's (adult diapers) were full of BM (bowel movement) and it was just a big misunderstanding. On 12/5/2025 at 8:45 AM, V1 stated the Facility was requesting past noncompliant (PNC) for F600 abuse even though through their investigation V1 stated she had no findings. V1 stated they did not believe the abuse occurred because (R2) use to be a certified nursing assistant, at this building. They did a PNC ready just in case. On 12/5/2025 at 8:49 AM, V2, Director of Nursing stated they did an internal…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-11-20 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to label medication per current standards of practice. This has the potential to affect all 99 residents residing in the facility.Findings include:R3's admission Record, dated [DATE], documents admission date [DATE] with Dementia, Chronic kidney Disease, hypertension, and Anxiety listed as diagnosis.R3's Care Plan, dated [DATE], documents that (R3) has potential for acute pain r/t (related to) dx (diagnosis) Dementia, Chronic Kidney Disease, GERD.R3's Physician Order, dated [DATE], documents Morphine Sulfate Oral Solution 20 MG/5ML (milligram/milliliter) Give 0.25 ml by mouth every 4 hours as needed for pain.R3's Controlled Drug Record documents 30ml bottle of Morphine Sulfate 100mg/5ml. It documents R3's name with a hand drawn line thru it and R5's name handwritten above it. It also documents on 9/16 at 9:20 0.25 ml given and at 5:45 0.25 ml given. A handwritten line is drawn across the Controlled Drug Record. It continues starting 29.50ml in bottle and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-11-20 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to prevent the misappropriation of a resident's narcotic pain medication for 1 of 3 (R3) residents reviewed for liquid narcotic medication in a sample of 6.Findings include:R3's Care Plan, dated [DATE], documents that (R3) has potential for acute pain r/t (related to) dx (diagnosis) Dementia, Chronic Kidney Disease, GERD.The facility's initial letter, dated [DATE], documents that the facility's medication tampering suspected by hospice nurse. Please find this as the initial reporting of Suspected medication tampering by hospice nurse during care provided to mutual resident of the facility. It appears that the nurse changed the label and repurposed a bottle of liquid medications from a deceased resident to a current resident. No harm occurred and the hospice company was notified, and an investigation initiated. A full report will follow upon completion of all investigation steps.R3's Physician Order, dated [DATE], documents Morphine Sulfate Oral Solution…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-11-20 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to document an appropriate reason for discharge from the facility, the specific needs of the resident that could not be met at the facility, the services available at the receiving facility and issue a notice for 1 of 3 (R2) resident's reviewed for Admission, Transfer & Discharge Requirements.Findings include:R2's admission Record, R2's Care Plan, dated 06/03/2025, documents I do not need to be asked about discharge on each assessment due to plans to remain in this facility long term. admission Record, print date 9/17/2025, documents that R2 was admitted to the facility 5/30/2025 with Unspecified Dementia, moderate with agitation and Schizophrenia listed as diagnosis.R2's Minimum Data Set, dated [DATE], cognitively intact with behaviors of delusions.R2's Progress Note, dated 7/30/2025, documents R2 was very angry, unable to redirect threats of self-harm and harm to others. Violent towards V2. 911 called. Resident aggressive with EMTs and police. Physical…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Fcited before2025-04-28 · tag F0761 — failed to label and store drugs safely — widespread
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to properly store and discard expired medications for 30 of 32 residents (R11, R15, R18, R23, R27, R29, R30, R31, R32, R35, R39, R40, R41, R43, R44, R45, R46, R48, R58, R60, R63, R65, R81, R82, R86, R94, R96, R97, R101, R357) reviewed for medication storage in the sample of 79. Findings include: On 4/21/2025 at 9:55 AM the facility's 100 Hall North Back Medication Cart was inspected. The medication cart contained the following: R41's opened multi dose Lantus insulin Pen. The multi-dose vial was labeled with no open date. On 4/21/2025 at 9:59 AM V4, Registered Nurse (RN), verified that the multi dose vial was open, in use and did not have an open date. On 4/21/2025 at 10:07 AM the facility 100 hall medication room was inspected. The unlocked refrigerator located in the medication room contained the following: R29's plastic sealable bag with 1 sealed 1ml vial of Lorazepam and 1 open and partially used 1ml vial of Lorazepam. 1 unlabeled plastic…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-28 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — pattern
    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview, Observation, and Record Review the Facility failed to provide timely and complete incontinent care for 4 of 5 residents (R18, R41, R42, R63) reviewed for incontinent care in the sample of 79. The Findings Include: 1. R18's admission Record, dated 4/22/25, documents R18 was admitted to the facility on [DATE] with diagnosis of Cerebral Infarction, Dysphagia, Dementia, Major Depressive Disorder, Anxiety Disorder, Trigeminal Neuralgia, and Morbid Obesity. R18's Care Plan, dated 11/6/24, documents R18 has an ADL (Activities of Daily Living) self-care performance deficit related to Limited Mobility. Interventions: Toilet Use: R18 is not toileted, she is frequently incontinent, unable to transfer to toilet, use of bedpan encouraged, incontinent care per staff. It continues (4/7/25) R18 has potential for impairment to skin integrity related to impaired mobility, current medications, incontinence of B&B (bowel and bladder). Interventions: Complete pressure ulcer risk assessment quarterly and PRN (as…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
Show the remaining 14 citations
  • Potential for harm · E2025-04-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — pattern
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on Interview, Observation, and Record Review, the Facility failed to provide a humidified bottle of water and to date the nasal cannula for 4 of 5 residents (R63, R65, R43, R13) reviewed for residents on Oxygen (O2) in the sample of 79. The Findings Include: 1. R63's admission Record, dated 4/22/25, documents R63 was admitted to the facility on [DATE] with diagnosis of Cerebral Vascular Accident (CVA) affecting dominant side, Hemiplegia, Hemiparesis, Chronic Obstructive Pulmonary Disease (COPD), Major Depressive Disorder, Generalized Anxiety Disorder, Polyneuropathy, Respiratory Failure with Hypoxia, Dependence on Supplemental Oxygen (O2), Morbid Obesity, and Type 2 Diabetes Mellitus (DM). R63's Care Plan, dated 11/13/24, documents R63 requires assistance with ADLs (activities of daily living) related to impaired mobility. Diagnosis CVA/hemiplegia. R63 has SOB (shortness of breath) with excretion, when lying flat R63 uses oxygen. Interventions: Assist with all ADLs as needed, observe for signs/symptoms or…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-28 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview the facility failed maintain a clean, homelike environment for 2 of 3 (R13, R27) residents reviewed for housekeeping in the sample of 79. 1. R13's MDS, dated [DATE], documents that R13 is cognitively intact. On 4/23/2025 at 1:29 PM R13 stated that the facility is filthy. R13 stated that the odor in the building is overwhelming. R13 stated that it's so many people that live here and not enough staff to take care of the building. R13 stated that the staff won't help each other and housekeeping only mop the floor. R13 stated they don't scrub it they only light run the mop that's it. 2. R27's MDS, dated [DATE], documents that R27 is cognitively intact. 04/23/25 at 02:28 PM R27 stated that the facility smells of urine and poop all the time. R27's BIMS is 15. R27 stated that there was a leak last time it rained heavy. 04/28/25 at 10:30 AM V14, CNA stated that she would let housekeeping know if a resident's room needs cleaned or if there are any foul odors so they can clean it and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-28 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to report allegations of abuse for 4 of 4 (R36, R38, R49, R358) residents reviewed for Abuse in the sample of 79. 1. R36's Care Plan, not dated, does not document R36's risk for or interventions to prevent abuse. R36's Minimum Data Set (MDS), dated [DATE], documents moderately cognitively impaired. On [DATE] at 9:27 AM observed R36 and R38 striking each other with closed fist. R38 yelled out and struck R36 repeatedly, with closed fist on the arm, hand and shoulder. R36 then grabbed R38's arm and swung closed fist at R38, making contact with R38's chest. R38 continued to yell out and push the door into R36's wheelchair and R36's arm. V29, Safety Aide, intervened and attempted to calm the residents. V29 instructed the residents to stop then removed R38's hand from R36's arm. R38 was then taken from room. On [DATE] at 3:50 PM reviewed R36's medical record. No documentation of the resident to resident altercation. On [DATE] at 11:30 AM R36's medical record…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-28 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to investigate allegations of abuse for 1 of 4 (R38) residents reviewed for allegations of abuse in the sample of 79. Findings include: 1. R38's Progress Note, dated 4/18/2025 at 5:05 PM, documents that Resident has been angry and agitated this shift. He has been yelling and cursing at other Residents and staff. Re-directed him and explained that his behavior is not appropriate. Resident finally calmed down and allowed staff to help him with his ADL's. Will continue to monitor. On 4/22/2025 at 10:00 AM request abuse investigations. As of 4/28/2025 at 2:00 PM the facility had not provided an investigation for verbal altercations occurring on 4/15/2025 and 4/18/2025. On 4/22/2025 at 1:15 PM V4, RN, stated that there was an incident that happened last week when R38 was cursing at other residents. V4 stated that she notified the Director of Nursing. On 4/28/2025 at 12:25 PM V2, Director of Nursing, stated that incidents on 4/15/2025 and 4/18/2025 were reported to IDPH on 4/22/2025. V2 stated that they were made aware of the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-28 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record reviews the facility failed to refer a resident to the appropriate state-designated mental health or intellectual disability authority for review after being diagnosed with a serious mental disorder, intellectual disability or related condition for 1 out of 1 resident, (R53); reviewed for Coordination of PASARR (pre-admission screening and resident review) in a sample of 79. Findings include: R53's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, heart valve replacement, atrial fibrillation and congestive heart failure. R53's face sheet documented he was diagnosed with severe dementia with agitation on 11/8/24, dementia with psychotic disturbance on 11/6/24 and schizoaffective disorder, depressive type on 12/29/23. R53's Minimum Data Set (MDS) dated [DATE] documented he was severely cognitively impaired, had non-Alzheimer's dementia, schizophrenia and had not received psychological therapy in the last 7 days. R53's Care Plan…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-28 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, observations, and record reviews the facility failed to perform hand hygiene and removal of dirty gloves for 1 out of 1 resident, (R56); reviewed for infection control in a sample of 79. Findings include: R56's face sheet documented he was admitted to the facility on [DATE] with diagnosis of, in part, rhabdomyolysis, Alzheimer's disease and dementia. R56's Minimum Data Set (MDS) dated [DATE] documented he was severely cognitively impaired and requires partial/moderate assistance for toileting hygiene and shower/bathing self and is frequently incontinent of bladder. On 4/23/25 at 10:45 AM, R56 had saturated his incontinence brief and his pants with urine and had a small amount of stool present. V26, CNA, did not perform hand hygiene after peri care on R56 and removing his gloves. V24, CNA, did not removed her gloves and perform hand hygiene after touching R56's soiled clothing and placing them in a trash bag. V24 then touched R56's wheelchair handles and R56's hands, body and gait belt while…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-06-18 · tag F0600 — failed to protect residents from abuse and neglect — pattern
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to prevent resident to resident abuse for 4 of 6 residents (R3, R5, R35, and R259) reviewed for abuse in the sample of 45. Findings include: 1. R35's Physician Order Sheets (POS) dated June 2024 documents R35's diagnoses of Hyperlipidemia, type 2 diabetes mellitus without complications, hypertension, benign prostatic hyperplasia without lower urinary tract symptom, patient noncompliant with other medical treatment and regimen related unspecified. Muscle weakness, and unspecified dementia. R35's Minimum Data Set, MDS, dated [DATE] documents R35 was severely impaired for cognition for activities of daily living. R35's Care Plan with a Problem Onset date of 10/31/2023 documents, (R35) is at risk for psych-social concerns . on 10/31/2023 in which he was reported to have hit another resident with his walker (upon review this was noted to be unintentional, unfounded abuse). R35's Progress Notes dated 10/31/2023 at 9:20 PM, This shift at 3:45…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-06-18 · tag F0760 — failed to prevent significant medication errors — pattern
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review the facility failed to prevent significant medications errors regarding insulin administration for 4 of 6 residents (R16, R41, R42 and R104) reviewed for significant medication errors in the sample of 45. Findings include: 1.R41's Physician's Order Sheet (POS), dated June 2024, documents, diagnoses of long-term use of insulin, other lack of coordination, tremor, cerebral ataxia in disease classified elsewhere, type 1 diabetes mellites with hypoglycemia without coma. R41 has an order for NovoLog 100 unit/ML Flexpen Administer 8 units prior to meals with the correctional scale following 70-200= none, 201-250 = 2 units, 251-300= 3 units, 301-350- 4 units, 351-400= 5 units, 401-450= 6 units, 451 or higher 7 units DO not hold insulin. R41's Care Plan Problem with onset date of 1/26/2020 documents, (R41) is at risk for falls and has a history of actual falls related to balance issues and diagnosis of cerebral ataxia, hypertension which being treated, pain in right knee tremor unspecified, other lack of coordination, pain, insomnia and diabetes with low…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-06-18 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to administer medications as ordered for 1 of 5 residents (R46) reviewed for pharmacy services in the sample of 45. Findings include: On 6/12/24 at 10:44 AM, R46 stated he is supposed to get Tylenol 500 milligrams (mg) three times daily (TID) at 6:00 AM, 2:00 PM and 10:00 PM because he has chronic pain. He stated the regular nurses are very good about getting his medications timely but when the agency nurses are here, he doesn't always get his Tylenol as ordered. He stated his pain is pretty well controlled, but he just wished the agency nurses would pay closer attention. R46's Diagnoses/ History dated 11/7/23 documents his diagnoses to include Other Chronic Pain and Wedge Compression Fracture Fourth Lumbar Vertebra, Subsequent for fracture with routine healing. R46's Physician Orders dated May 2024 documents the order dated 3/13/23: Tylenol Extra Strength 500 milligram (mg) caplet-give 2 tabs by mouth (po) TID (three times a day) at 6:00 AM, 2:00 PM and…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-05-23 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the Facility failed to administer insulin timely as prescribed by physician for 1 of 3 residents (R2) reviewed for medications in the sample of 4. Findings include: R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including major depressive disorder with psychiatric symptoms, schizoaffective disorder, borderline personality disorder, and type 2 diabetes mellitus. R2's Undated Minimum Data Set (MDS) printed 5/22/24 documented R2 was cognitively intact, had verbal behavioral symptoms directed at others every one to three days, and was independent with activities of daily living and ambulation. R2's May 2024 Physician Orders document order for Basaglar 100 units/mL (milliliter) Kwikpen, inject 30 units subcutaneously twice per day. R2's Medication Administration Record (MAR) for the month of February 2024 documents circled initials around the 8:00 PM dose of Basaglar 100 units/mL Kwikpen, inject 30 units subcutaneously twice per day, along with…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-05-09 · tag F0881 — failed to use antibiotics responsibly — pattern
    Implement a program that monitors antibiotic use.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the Facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use in 4 of 7 residents (R2, R28, R68 and R303) reviewed for antibiotic stewardship in the sample of 51. Findings include: 1. The Facility's Infection Log documents No culture done as the pathogen causing R2's 12/7/22 urinary tract infection (UTI) to ensure medication prescribed was effective in treating R2's UTI. R2's Physician Orders for the month of December 2022 documents order for 300 mg (milligram) Cefdinir capsule - give 1 cap PO (by mouth) BID (twice daily) for dx (diagnosis) of UTI (urinary tract infection) with start date of 12/7/22. The order documents, Need stop date. R2's Medication Administration Record (MAR) for the month of December 2022 documents R2 received 15 doses of the antibiotic Cefdinir. R2's Urine Culture and Sensitivity (C&S) was requested on 5/4/23 at 1:50 PM. On 5/9/23 at 8:00 AM, no C&S was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-09 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility failed to report an injury of unknown origin to the Illinois Department of Public Health (IDPH) for 1 of 3 residents (R29) reviewed for reporting of abuse allegations in the sample of 51. Findings include: R29's Face Sheet documents R29 was admitted to the facility on [DATE] and has diagnoses including hyperlipidemia, anemia, anxiety disorder due to known physiological condition, gastro-esophageal reflux disease without esophagitis, essential (primary) hypertension, insomnia, and major depressive disorder. R29's Minimum Data Set (MDS) completed 3/16/23 documented R29 was severely cognitively impaired, required extensive one person assistance with bed mobility and transfer, and had no documented skin conditions. R29's Care Plan, undated, does not address risk of abuse. On 5/3/23 at 10:00 AM V8, R29's Family Representative, stated she is very involved with R29's care and visits her daily at the facility. V8 stated during her visit on 4/13/23, she…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-05-09 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the Facility failed to investigate an injury of unknown origin for 1 of 3 residents (R29) reviewed for investigation of abuse in the sample of 51. Findings include: R29's Face Sheet documents R29 was admitted to the facility on [DATE] and has diagnoses including hyperlipidemia, anemia, anxiety disorder due to known physiological condition, gastro-esophageal reflux disease without esophagitis, essential (primary) hypertension, insomnia, and major depressive disorder. R29's Minimum Data Set (MDS) completed 3/16/23 documented R29 was severely cognitively impaired, required extensive one person assistance with bed mobility and transfer, and had no documented skin conditions. R29's Care Plan, not dated, does not address risk of abuse. On 5/3/23 at 10:00 AM V8, R29's Family Representative, stated she is very involved with (R29's) care and visits her daily at the facility. During her visit on 4/13/23, V8 stated she observed bruising on the back of R29's hands that was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-05-09 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review, the facility failed to ensure medications were given as ordered. There were 27 opportunities with 2 errors resulting in a 7.41% medication error rate. The errors involved 2 residents (R10, R51) in the sample of 51 out of 3 residents observed during medication administration. Findings include: 1. On 5/3/2023 at 7:27 AM, V6 Licensed Practical Nurse (LPN), administered medications to R10. V6 administered D3-5 (vitamin D) 125 micrograms (mcg)/5,000 units (IU) to R10. R7's Physician's Order Sheet (POS), dated 5/2023 documents the physician's orders to administer vitamin D 1,000-unit tablet 1 tablet once daily for vitamin deficiency. On 5/3/2023 at 8:37 AM V6, Licensed Practical Nurse (LPN) looked at the D3-5 bottle that she administered to R10, and she stated it wasn't the correct dose because R10's MAR (Medication Administration Record) documents the D3 dose was 1,000 units. V6 went through the stock medication drawer and through several of the medication drawers on the cart and didn't find D3 1,000-unit bottle. 2. On 5/3/2023 at 7:45…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$279,894 in federal fines across 4 penalties. 1 Medicare payment denial on record.

  • $97,240 — penalty dated 2025-12-16
  • $58,045 — penalty dated 2025-04-28
  • $75,137 — penalty dated 2024-12-26
  • $49,472 — penalty dated 2023-10-19
  • Medicare payment denial — starting 2025-05-22 for 7 days

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Who owns this facility

Owner / managerTypeRoleSince
Ownership Data Not Available

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$8.1M
Net patient revenuemost recent cost report
-31.5%
Operating marginrevenue minus expenses
$819K
Related-party expense8% of expenses
Who pays — share of resident-days
Medicaid 82%Medicare 8%Other / private 10%

About 82% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $819K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$313per resident / day
operating cost
$9,514per month
≈ monthly operating cost
$238per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in IL

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Illinois Medicaid page.

Typical monthly cost in Illinois
$8,304/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,219/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 145847. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-28, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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